Margaret A. Struchen

Comparison of indices of traumatic brain injury severity: Glasgow Coma Scale, length of coma and post-traumatic amnesia

Background: Classification of traumatic brain injury (TBI) severity guides management and contributes to determination of prognosis. Common indicators of TBI severity include Glasgow Coma Scale (GCS) scores, length of coma (LOC) and duration of post-traumatic amnesia (PTA). Objective: To compare GCS, LOC and PTA by examining distributions and intercorrelations and develop multivariable linear regression models for estimating LOC and PTA duration. Methods: Prospective study of 519 of 614 consecutive patients with TBI. Indices of TBI severity studied were GCS, LOC, PTA and PTA–LOC (the interval from return of command-following to return of orientation). Candidate predictor variables for estimation of LOC, PTA and PTA–LOC intervals were age, years of education, year of injury (before 1997 vs 1997 or later), GCS, LOC (for PTA and PTA–LOC), pupillary responsiveness, type of injury, CT pathology and intracranial operations. Results: Although there was a severity/response relationship between GCS and LOC, PTA and PTA–LOC intervals, there was overlap in these intervals between GCS severity categories. Age, year of injury, GCS, pupillary responsiveness and CT pathology were predictive of LOC. Age, years of education, year of injury, GCS, LOC, pupillary responsiveness and intracranial operations were predictive of PTA duration. Age, years of education, year of injury, GCS, LOC and pupillary responsiveness were predictive of PTA–LOC. GCS and LOC effects were influenced by age. Conclusions: Predictors for estimating LOC, PTA and PTA–LOC intervals were determined and simple equations were developed. These equations will be helpful to clinicians, researchers and those counselling family members of patients with TBI.

Neuropsychological Assessment and Employment Outcome After Traumatic Brain Injury: A Review

While there may be many reasons for obtaining neuropsychological assessment after traumatic brain injury (TBI), prediction of real world functioning is generally a key goal. The present paper reviews 23 studies concerning the relationship between neuropsychological test results and employment outcome after TBI. The review was conducted in accordance with guidelines developed by the Committee on Empirically Supported Practice of Division 40 (Neuropsychology) of the American Psychological Association. Results of the review support a Category A (strongly supported) recommendation for the use of early neuropsychological assessment to predict late employment outcome. Studies of late neuropsychological assessment and subsequent employment outcome and studies of concurrent neuropsychological assessment and employment outcome were inconclusive regarding either support or contraindication for neuropsychological assessment to predict employment outcome. Almost all studies conducted at these late or concurrent time points had significant limitations with regard to study type or adequacy of methodology. However, there is no conceptual basis for believing that neuropsychological findings obtained closer in time to assessment of employment outcome should be less predictive of this outcome than neuropsychological findings obtained at an earlier time.

The Relation Between Acute Physiological Variables and Outcome on the Glasgow Outcome Scale and Disability Rating Scale Following Severe Traumatic Brain Injury

The relation between outcome and duration of adverse physiological events was studied, using suggested critical physiological values. Subjects were 184 patients with severe traumatic brain injury who received continuous monitoring of intracranial pressure (ICP), mean arterial pressure (MAP), cerebral perfusion pressure (CPP), and jugular venous oxygen saturation. Longer durations of adverse physiological events were significantly related to Glasgow Outcome Scale (GOS) scores and Disability Rating Scale (DRS) scores for all variables at all timepoints postinjury. When analyses excluded patients who died, the relation between adverse physiological events and GOS was nonsignificant; however, duration of ICP, MAP, and CPP still accounted for a significant portion of the variance in DRS scalres. The relative sensitivity of the GOS and DRS is discussed.

Examining the contribution of social communication abilities and affective/behavioral functioning to social integration outcomes for adults with traumatic brain injury

Objective:To evaluate the contribution of social communication abilities and affective/behavioral functioning to socialintegration outcomes for persons with traumatic brain injury (TBI). Design:Prospective cohort study. Participants:A total of 184 adults with TBI (72.8% men) evaluated at least 6 months postdischarge from acute care orinpatient rehabilitation hospitals and after living at least 3 months in the community postdischarge (Mean = 7.84 monthspostinjury). Measures:La Trobe Communication Questionnaire (LCQ), Assessment of Interpersonal Problem-Solving Skills(AIPSS), Affective Behavioral subscale From the Problem Checklist of the Head Injury Family Interview (AB-HIFI), Craig HandicapAssessment and Reporting Technique–Short Form Social Integration subscale (CHART-SF-SI), Community Integration QuestionnaireSocial Integration subscale (CIQ-SI). Results:Social communication measures (LCQ, AIPSS) and self-reported behavioralfunctioning (AB-HIFI) contributed significantly to concurrently measured social integration outcomes after controlling for demographicand injury-related variables. Separate hierarchical multiple regression analyses revealed that social communication and behavioralvariables accounted for 11.3% of variance in CIQ-SI and 16.3% of variance in CHART-SF-SI. Conclusions:Social communication abilities and affective/behavioral functioning make a substantial contribution to social integration outcomes after TBI. The implications of such evidence for clinical assessment and intervention are discussed.

Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.

Objective:To explore qualitatively the experience of intimacy from the viewpoint of persons with traumatic brain injury (TBI) and their intimate partners. Design:Qualitative interview study. Setting:Outpatient community. Participants:Eighteen persons with TBI and their intimate partners at a mean length of 4.78 years postinjury. Main measures:Open-ended, semistructured, in-depth interviews regarding participants’ experience of intimacy, factors impacting intimacy, and need for services. Results:Factors that were perceived as helping relationships remain strong included unconditional commitment, spending time together, open communication, a strong preinjury relationship, bonding through surviving the injury together, social support, family bonds, spirituality, experience with overcoming hardship, and coping skills. Factors that were perceived as barriers to intimacy included injury-related changes, emotional reactions to changes, sexual difficulties, role conflict and strain, family issues, social isolation, and communication issues. Conclusions and Implications:Education regarding the impact of TBI on intimacy should be integrated into rehabilitation. Health professionals should be sensitized as to the needs that persons with TBI and their partners have regarding intimacy and how to make appropriate referrals to assist them.

A multidimensional measure of caregiving appraisal: validation of the Caregiver Appraisal Scale in traumatic brain injury.

Objective:To investigate the factor structure and concurrent validity of the Caregiver Appraisal Scale (CAS) in a sample of caregivers of adults with traumatic brain injury (TBI). Design:Prospective cohort study. Setting:Two sites: (1) Outpatient clinics associated with a comprehensive inpatient brain injury rehabilitation program and (2) a comprehensive residential postacute rehabilitation program in the Southern United States. Participants:One hundred forty-nine caregivers of adults with TBI enrolled in the TBI Model Systems Project and 92 caregivers of adults with TBI admitted to a residential postacute rehabilitation program. Most caregivers were women and either parents or spouses of the injured person. Main Outcome Measures:Caregiver Appraisal Scale (CAS); Subjective Burden Scale (SBS); Objective Burden Scale (OBS); General Health Questionnaire (GHQ). Results:Principal components analysis with varimax rotation yielded four factors: perceived burden (PB), caregiver relationship satisfaction (CRS), caregiving ideology (CI), and caregiving mastery (CM), which were found to be fairly stable across treatment settings. Adequate concurrent validity was demonstrated for the perceived burden factor, and adequate internal consistency was found for three of four scales. Conclusions:Preliminary support for the use of the CAS in caregivers of adults with TBI was obtained. However, further scale development, particularly for the CM factor, will likely improve the stability and usefulness of this instrument.

Long-term maintenance of gains obtained in postacute rehabilitation by persons with traumatic brain injury.

Objective:To investigate maintenance of gains after discharge from a postacute rehabilitation program. Design:Longitudinal cohort study, with inclusion based on availability of subjects at three time points. Setting:Comprehensive postacute rehabilitation program in the Southern United States. Participants:Thirty-four persons with medically documented complicated mild to severe traumatic brain injury; primarily male Caucasians with some college. Main Outcome Measures:Disability Rating Scale and the Community Integration Questionnaire completed at admission, discharge, and two follow-up time points. Results:Repeated measures analyses, using time from injury to discharge as a covariate, revealed significant improvements on all measures from admission to discharge, with no significant change from discharge to either of the follow-up periods. However, substantial changes were noted in individual cases. Conclusions:The results indicate that gains made by persons with traumatic brain injury during postacute rehabilitation are generally maintained at long-term follow-up, but changes occur in individual cases. Long-term services may help prevent decline in individual cases.

Making connections after brain injury: development and evaluation of a social peer-mentoring program for persons with traumatic brain injury.

Objective:To describe the development and implementation of a social peer-mentoring program for persons with traumaticbrain injury (TBI) and to explore whether this program yielded increased social functioning outcomes compared with wait-list (WL)controls. Design:Pilot randomized controlled study. Participants:Community-dwelling individuals with TBI(12 matched with social peer mentors and 18 completing the WL condition). Intervention:Trained social peer mentors (SPMs)were matched to partners with TBI (peer partners (PP)) to foster skill-building in planning of social activities and improvingsocial communication abilities through phone contacts and joint participation in social events within the community over a 3-monthperiod. Measures:Social Activity Interview, Center for Epidemiological Studies Depression Scale, UCLA Loneliness Scale, Satisfaction with Life Scale, 6-Item Interpersonal Support Evaluation List (baseline and postmentoring); weekly social activity data(1-month baseline, continuously collected during 3-month mentoring or WL period); satisfaction survey. Results:Both SPMand PP participants reported high satisfaction with the mentoring program. Statistically significant improvements in perceived socialsupport after mentoring were observed for the mentored group than for WL participants; however, an increase in depressive symptoms wasalso observed. While significant improvements in social activity level and social network size were not found, a trend toward increasedsatisfaction with social life was present for mentored participants. Conclusions:Satisfaction ratings for the SPM programwere uniformly high and selected positive findings encourage further investigation of social mentoring as an intervention to effectimprovements in social integration. Small sample size and reduced “dosage” of mentor interactions were limitations of thispilot study. Benefits of and challenges to implementation of an SPM program are outlined.

Relationship of race/ethnicity and income to community integration following traumatic brain injury: investigation in a non-rehabilitation trauma sample.

The purpose of the current study was to determine the contribution of race/ethnicity and income to community integration at approximately 6 months following traumatic brain injury (TBI). Participants were 151 persons with mild to severe TBI (38% Black; 38% Hispanic; 24% White) recruited from consecutive admissions to the Neurosurgery service of a county Level I trauma center. A large number of participants had low income and low education. Community integration was assessed using the Community Integration Questionnaire (CIQ), Craig Handicap Assessment and Reporting Technique - Short Form (CHART-SF), and Community Integration Measure (CIM). Results of analysis of covariance (ANCOVA) indicated that, after accounting for injury severity, age, education, and income, race/ethnicity contributed significantly to the variance in CIQ Total score, Home Integration Scale, and Productive Activity Scale scores. Blacks had lower CIQ Total scores compared to Whites. Black and Hispanic participants had lower scores than Whites on the Home Integration Scale, and Blacks had lower scores than Whites and Hispanics on the CIQ Productive Activity Scale. Low income ( < or =

Perceptions of communication abilities for persons with traumatic brain injury: Validity of the La Trobe Communication Questionnaire

20,000) was related to lower scores on the CIQ and CHART-SF Social Integration Scales, and scores on the CIM Total, Belonging, and Independent Participation scales. These results indicate that racial/ethnic differences in community integration exist, even after accounting for income. However, income was more predictive than race/ethnicity for certain aspects of community integration, indicating that it should be accounted for in all studies investigating racial/ethnic differences in outcomes.